A Sandhurst woman who lit 17 candles for a romantic meeting with an imaginary boyfriend died in a blaze in her flat the same day, an inquest has heard.

Jane Ellis had long harboured a make-believe relationship with a man she called Ian.

She was assessed by mental health experts at her home in a block of flats in Oxford Road on Friday, February 6 last year.

The following day, after Ms Ellis had lit the candles for her ‘date’, neighbours knocked on her door to say the building was on fire.

She slammed the door shut and ignored the warnings, the inquest was told.

She was later found lying face-down on the bathroom floor, following the blaze.

She was airlifted to hospital in an induced coma but died on February 8.

Jane was flown to St George's Hospital in Tooting but could not be saved (Image: Google)

Family, friends, care workers and her GP all criticised a crisis mental health care team for leaving her alone in the flat but a fire investigator was unable to pin down the exact cause of the fire.

Peter Bedford, the senior coroner for Berkshire, was told last week that relatives of 46-year-old Ms Ellis believed more should have been done to have her sectioned under the Mental Health Act so she could be put in a place of safety.

He heard her family were dismissed as ‘making a big fuss’ when they tried to get her admitted to a psychiatric hospital.

Following a three-day inquest in Reading which ended last Thursday, Mr Bedford recorded a verdict of accidental death.

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He ruled that systematic and operational failings at Berkshire NHS Trust revealed by the case had been addressed with extra staff, audit checks, training and £1 million in extra funding for its mental health services.

Mr Bedford said: “I take the view that I don’t need to raise such a report because the trust has beaten me to it.”

Mr Bedford had heard that when relatives raised concerns that Ms Ellis might set her flat on fire, staff at the crisis mental health team told them it was not an emergency service and to call police if there was an immediate welfare risk.

'Preventable incident'

Ms Ellis’ brother-in-law, Andrew Manley, told the coroner: “In my opinion, this was an entirely preventable incident, had Jane been put in a safe place and adequately monitored until she became well.

"We were pleading to speak to the assessor to give further information about her and were refused point blank from doing so.

“If the candles were being used to contact an imaginary boyfriend, you can at least appreciate there is some risk there.”

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The family’s barrister, Hannah Noyce, had asked for a ‘narrative verdict’, which would allow the coroner to make more wide-reaching conclusions about the circumstances of the death.

She said: “There has been sufficient evidence of systematic and operational failings by the trust as a whole, rather than by individuals, to justify a conclusion of those terms – inadequacy of resources and staffing within the crisis team in particular.”

Yet the coroner ruled that she died by accident after fire investigator Chris Bunyan told the inquest the cause of the blaze could not be determined but was either deliberate, a discarded cigarette, a naked flame or an accidental electrical fault.

A post-mortem examination showed that the cause of death was a hypoxic brain injury as a direct consequence of the fire.

Ms Ellis was flown to St George’s Hospital in Tooting, but was taken off of life-support after her family were told her ‘extremely poor prognosis’ meant efforts to save her life were futile.